Photo illustration of DNA in a test tube

The Role of Pharmacogenetic Testing in Prescribing Medications

Typically, doctors prescribe drugs based on factors including a patient’s age, weight, sex and liver and kidney function. For some drugs, researchers have discovered genetic markers to target when treating a disease. In those cases, a certain kind of genetic testing can be used to determine the right drug for a patient. It’s called pharmacogenetic testing.

When Pharmacogenetic Testing is Used

Some drugs on the market are so specific, a patient must have a certain genetic mutation for the drug to be effective, and then both the manufacturer and U.S. Food and Drug Administration will require patients to undergo pharmacogenetic testing before the drug can be prescribed to them.

This is the case for some newer drugs for cancer and cystic fibrosis. For example, the breast cancer drug called Talzenna has package labeling that requires pharmacogenetic testing. The drug will only be effective if a patient has certain types of genetic mutations – and so pharmacogenetic testing is necessary first to see if the patient is eligible for the drug.

Pharmacogenetic Testing and Blue Cross Coverage

If a doctor recommends that a patient undergo pharmacogenetic testing, the patient’s insurance company may have a process to review that request before making a coverage decision.

As a standard, Blue Cross Blue Shield of Michigan provides coverage for pharmacogenetic testing in cases where the test is required by the manufacturer and the FDA for the patient to be prescribed the drug. Pharmacogenetic testing is billed under a patient’s medical benefit, while the drug itself is billed under a patient’s pharmacy benefit. Having both medical and pharmacy coverage through the same plan ensures the most efficient care coordination, since medication and claim reviews confirm each prescription is the appropriate treatment for the patient’s specific needs.

The future of pharmacogenetic testing is promising as precision medicine that aims to treat each patient individually becomes more common. As the medical field continues to produce drugs that are more complex and more specific, the need for genetic testing will continue to grow. Tailored drugs could be available in the future to treat heart disease, Alzheimer’s disease, HIV/AIDS and asthma.

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